Circumcision: a Question of Health or Politics?

If I were a Kenyan man and someone said, "hey, you could reduce your chances of contracting HIV by 60% if you get circumcised", I don't think I'd take up the offer. Health services in Kenya have been declining since the 70s and a recent study showed that the rate of adverse effects from clinically performed circumcisions in Bungoma, Western Kenya, stood at 17%. To be fair, I also came across an article that said that the rate of adverse effects in another programme stood at below 1% but it didn't cite any authority for this claim. And in the end, you have to look at things in a pragmatic way; Kenya has not been spending much on health or other social services for several decades, personnel levels are low, training budgets are poor to non-existent, morale in the health services is terrible. Conditions just don't seem good for a mass male circumcision (MMC) campaign.

But I would also question why people who don't want to use condoms, for whatever reasons, would risk an operation that may not even give them the level of protection they need. Are people queuing up to be circumcised, perhaps, because they don't want to use condoms and they think being circumcised will obviate the need for these? The article claims that health services are "struggling to meet demand" for circumcision, which certainly doesn't inspire confidence in health services that were already stretched beyond breaking point. But apparently this campaign also tells people that circumcision only provides partial protection and that they need to continue to use condoms.

So if they don't bother getting circumcised but just use condoms instead, they would achieve higher levels of protection from HIV than if they go for circumcision and don't bother using condoms any more? Well, as I said, the campaign also involves persuading people to use condoms but we know that this is a very hard sell. In fact, condoms protect against a number of sexually transmitted infections and unplanned pregnancies, something circumcision doesn't do so well. So of course, the combination of circumcision and consistent condom use should be a good bet. But it sounds as if a mass male circumcision campaign would cost a lot of money and only benefit a relatively small part of the population (unlike condom-use campaigns, sex education, gender equality, better legislation, etc).

A writer in The UK Guardian has a soul-searching piece about how many infections and deaths could have been prevented if the HIV community had acted on evidence from the mid 80s that circumcision reduces HIV transmission rates. He asks why formal trials didn't start until nearly 20 years later and why it is at this late stage that MMC campaigns are being implemented. Well, maybe the author is right, maybe it is shocking that HIV prevention interventions that could have been implemented over two decades ago were ignored. But I don't think this author or the experts he interviewed should be so hard on themselves. There are so many reasons why HIV spread rapidly in Kenya and other countries, low rates of circumcision could only have played a small part.

For a start, we knew long before the 80s, before HIV had ever been heard of, that people who don't have enough food or water will die. We knew that sick and unhealthy people are more susceptible to disease, any disease, than healthy people. We knew that poorer people face more health risks than richer people. We knew that less well educated people were likely to have worse health than educated people. We knew that people without alternatives would take risky jobs and take more risks in their jobs. We knew that trade policies that only benefit rich countries at the expense of poor countries will make poor countries poorer (for peat's sake, it's a tautology!) and we knew many, many other things that we failed to act on. We are still failing to act on them. These issues are all, either directly or indirectly, related to HIV transmission.

Worse still, international financial institutions spent the 80s, 90s and 2000s giving loans to developing countries on condition that they reduced spending on health, education and other social services, especially infrastructure spending and personnel costs. The HIV prevention programmes that have been implemented since HIV has been identified, such as they were, required the very structures that were being dismantled and continue to be dismantled to this day!

MMC is just one possible HIV reduction programme out of many. But like all other HIV reduction programmes, it will run up against the same problems, such as lack of adequate health services, low levels of health education and adult literacy, poor infrastructure, few social services, etc. If MMC can prevent the millions of infections claimed by experts, such campaigns will require a lot more than training hundreds of masked scalpel wielders. They will need well funded health, education and social services. These latter criteria may or may not have been within reach in the 80s but now, so many years later, they are not even on the development agenda.

I'm not dismissing MMC as one possible intervention out of many. Once the controversies have been cleared up, and there are many, it may have its uses. I'm just wondering why there seems to be so much pressure to spend a lot of money on an intervention that could only benefit a relatively small minority of Kenyans, at best. About 75% are already circumcised. I also think that MMC is a pretty high risk intervention to implement in a country that has so many other health needs and so little health capacity.

The links between environmental conditions with acute respiratory infections and the links between water and sanitation with water borne diseases, for example, have been recognised for a hell of a lot longer without a damn thing being done about them. And a lot more people die from these than from HIV/AIDS. Given that the powers that be are not usually interested in cost effective measures that save many lives and vastly increase the health of many others, why would they be interested in measures that could, at most, affect a relatively small number of lives?

Why should this particular ‘missed opportunity’ receive so much attention and funding, and why now? Is it really true to say that ‘millions of lives could have been saved’ had MMC been introduced long ago. And if it is true, what about the millions more that could have been saved by attending to the many, far more serious areas of development? There seems to be something inherently more political than humanitarian about MMC.